Patient care is excellent and affordable, allowing women (and men) access to all the available methods of diagnosis, breast pathology treatment and counselling through an integrated, education orientated, multicultural navigator multidisciplinary approach, ensuring cost-effective service delivery and high-quality patient care.
The private-based sister unit hosted at Milpark hospital (The Breast Care Centre of Excellence [BCCE]) offers identical multidisciplinary treatment regimes. This unit is the only internationally accredited unit in Africa with full accreditation from the National Accreditation Program for Breast Centres.
Holistic care from diagnosis to treatment and survivorship is offered next to the Milpark hospital in an old heritage site hotel. The unit also provides funding support to the government unit for patient navigators, media awareness, and miscellaneous (though often critical consumables) if and when required.
The symbiotic relationship between the HJH government multidisciplinary breast unit and the private sector Netcare Breast Care Centre (NBCC) has proven to be a successful collaborative venture in South Africa and is recognised in neighbouring African states as an example of how a partnership between funded private medical healthcare and non-funded. This collaborative venture is proof that government services can equate to the highest quality multidisciplinary care for all.
Evolution of BCa treatment
Breast cancer (BCa) treatment has evolved over the last 50 years, from a disease treated mainly in the hands of the surgeon to now being a showcase for multidisciplinary team management. Advancement in the understanding of oncological care has resulted in swings from extensive radical surgery (Halstedian mastectomies) to breast-conserving treatment (BCT). Greater understanding of tumour biology has seen tremendous strides in the use of oncological drugs and the paradigm shift around understanding cancer spread.
- For every 100 people seen in a breast health practice, only 10% will require surgery
- Whilst history taking is essential, 65% of women diagnosed with BCa have no significant risk factor history
- Whatever the patient arrives with at your unit, review the data
- Work out costs prior to biopsies, and discuss this with your patient
- Should you be practising ‘solo’, you should attach yourself to a multidisciplinary team to ensure safe care. From a professional growth and medico-legal safety, this is essential for all surgeons that are not working in a dedicated breast centre.
Prior to diagnosis
Practice clinical, pathology and radiology review
- Pathology before any surgery: there is no role for surgical biopsies as an initial diagnostic tool
- Radiology review in a multidisciplinary meeting: to determine the assessment of needle biopsy accuracy
- Review all pathology and radiology independently: The use of magnetic resonance imaging (MRI) scans and elastography are valuable adjuncts to assess both breasts and regional lymph nodes to ensure adequate local staging prior to planning treatment.
The HJH breast unit recently incorporated the use of contrast-enhanced mammography (CEM). CEM involves the combined use of an intravenous (IV) iodinated contrast, with an optimal screening window of between two to six minutes post-contrast injection. Post-injection conventional mammogram images are obtained. The entire procedure takes 10 minutes. It allows for a similar assessment of neovascularity as MRI.
What is the new standard of care in management?
All patients should be discussed in the following multidisciplinary meetings:
- Clinical radiology meeting: during which correlation between the radiology and the core biopsy pathology should be documented including the need for further investigation
- A multidisciplinary oncology meeting: all treating disciplines (medical oncology, radiation oncology, radiology, pathology, surgical oncology genetics, oncology care physicians, nurse navigation [allied care specialists: lymphoedema, physio, nutritionists]) should be present when the patient is discussed. All decisions around the above meetings should be fed back to the patients with a clear plan of action around treatment.
Each unit should have written documentation of :
- Local treatment guidelines
- Which international guidelines are followed
- Which cases should be discussed that may fall outside of guidelines or require specific non-guideline based treatment choices and why.
If you are not part of a unit, find one that allows you to present your patients online. This is available through the BCCE with navigation feedback.
The pandemic has resulted in the greater use of online services, including a multidisciplinary meeting, which is beneficial for the practising solo specialists.
- Tumour, node, and metastasis (TNM)
- Biology of BCa
- Radiological assessment of the breast
- Mammography (quad, size, microcalcifications, multicentric, multifocality)
- Ultrasound size and nodal assessment
- Contrast mammography (new at HJH)
- Breast size.
Document all information at the start
Ensure the documentation of the treatment decision pathways, as well as those specific to your patient. All documentation should be circulated and include reasons for the clinical, radiological and treatment decisions.
Management pathway improvements
Placements of markers have evolved. Post-core biopsy marker placements are critical to delineate areas of either malignancy diagnosis or concern. The rule is that if there is a greater than 4% chance of the area being abnormal, a marker should be placed. Once the marker is placed, should the need for retrieval be required.
Guided localisation at the time of surgery is needed:
- What is historic: Skin tattoos to delineate concerning areas
- What is standard: Twirl markers and a variety of V markers
- What is new: Magnetic markers and wireless markers have long-term placement values. The value of magnetic markers is that surgical margins can also be assessed by determining the distance between the marker and the specimen border.
HJH, Milpark, and Cape Town are involved in the development of a novel long-term, cost-effective marker placement.
Who gets what surgery?
Today there is little reason for a woman not to choose BCT.
The absolute oncological indications for a mastectomy today are:
- Inflammatory BCa
- Multicentric BCa.
Relative oncological contraindications are:
- Paget’s disease
- Lobular carcinomas
- BCa gene (BRCA) positive.
A woman may elect to have a mastectomy or a bilateral mastectomy, but this is a psychological choice, not an oncological choice (with many reasons being cited):
- Strong family history
- Desire to avoid radiation due to logistics or personal reasons
- Sense of failure in radiology to detect a tumour either due to experience or not wanting future mammograms
- Aesthetic desires involving prosthetic reconstruction.
Before any woman decides on surgery, a detailed discussion explaining the following points must be made:
- Once a BCa diagnosis is made, that cancer determines the outcome, and irrespective of the BRCA or family history, a bilateral mastectomy becomes a choice, not an oncological decision
- The survival is equal whether a mastectomy or BCT is performed
- All women should be counselled around the oncology rules
- All women should be discussed in a multidisciplinary meeting
- A clear plan should be presented to the patient before starting treatment
- All women should be offered the opportunity for a second opinion.
BCa treatment does not involve ‘emergency cancer surgery ever’.
Breast conservation is not a contraindication in women with big tumours or women with locally advanced BCa, neither in women with metastatic disease.
Before discussing different surgical techniques for surgery and reconstruction, let us look at oncology principles that may guide surgery choices:
- Are you still doing axillary dissection, and if so, why? Sometimes less is more
- Do you mark your nodes prior to starting primary chemotherapy (ChT)
- Today the use of sentinel lymph node biopsies for node-negative axilla is the standard. Even in node-positive axillas, post-primary oncology treatment, targeted axillary sampling often replaces the need for an axillary dissection (which is seven lymph nodes).
Figure 1: Understanding the biology of BCa
Oncology treatment is the umbrella of care. This means understanding the biology of BCa as well as the T and N prior to treatment.
The general guidelines are that most triple-negative BCas get primary oncology treatment followed by surgery and radiation (except for a lazy subset of low Ki triple-negative cancers).
Most human epidermal growth factor receptor 2 (HER2) enriched BCa get primary HER2 treatment (either single or dual agent) prior to surgery. In addition, low Ki endocrine sensitive HER2 cancers can now get primary endocrine treatment with HER2 blockade prior to surgery.
Node positive luminal B cancers start with primary ChT, while locally advanced luminal A cancers should start with primary endocrine, and the new kid on the block CDK 4/6 inhibitors. This clever class of drugs shows huge potential with locally advanced endocrine sensitive cancers and metastatic endocrine sensitive cancers.
Early-stage luminal B cancers can start with surgery and sentinel lymph node biopsies followed by genetic profiling, thus avoiding the need for ChT in a subset. Early-stage luminal A cancers can start with primary endocrine therapy or primary surgery.
A subset of luminal A cancers in the elderly can probably avoid surgery and, if the tumours are single and node-negative, have cryo-surgery (freeze the cancers). Guidelines as to which patients do not require ChT according to genetic profiling must be documented.
The following questions must be addressed during oncological discussions:
- Which advanced patients do not require ChT? For example: extremely low Ki luminal A (low-grade lobular carcinomas ), node-positive disease can have primary endocrine treatment (as well as CDK 4/6 inhibitors ) if this has been discussed in a multidisciplinary meeting and authorised by a medical oncologist as the most suitable treatment route
- Which early-stage BCa patients will start with primary ChT? For example: triple negatives, HER2 enriched, high Ki luminal B
- Does your unit use specific ChT regimens for different tumour subtypes? Taxotere, adriamycin and cyclophosphamide for triple negatives
- How does your unit document response to primary ChT (clinically and radiological)?
- Poor responders to primary ChT are managed by second-line ChT ahead of surgery
- Incomplete responders post- ChT and surgery should be offered more oncology treatment options (CREATE for triple negatives) and watch and wait.
What endocrine treatments are offered to what patients and for how long?
Things to consider:
- Do you use extended adjuvant endocrine for all?
- Do you offer your young BCa patients an aromatase inhibitor plus gonadotropin-releasing hormone?
- Are gynaecological assessments offered to your patients (they should have yearly assessments and are all young patients who fit criteria for fertility treatment being offered counselling and a fertility assessment.
All patients should have documentation of the need for radiation with BCT. Discussions should include:
- Whether the patient fits criteria for intra-operative radiation should be assessed according to the American Society for Radiation Oncology guidelines
- Need for radiation due to axillary nodal disease (one or more involved)
- Whether the unit accepts and follows the Z11 protocol for radiation, thus avoiding more axillary surgery, as well as the After Mapping of the Axilla: Radiotherapy Or Surgery (AMAROS) study outcomes
- The pros and cons of hypo-fractionated treatment and whether the patient fits the criteria
- Can radiation possibly be avoided in certain elderly luminal A tumours?
- Availability of intraoperative radiation therapy and use to decrease government load.
Defining oncoplastic surgery
Oncoplastic surgery is defined as techniques used at the time of BCT. Whereas this term has been used for many years, it is my opinion that it should be termed onco-reconstructive techniques.
The basis of this surgery is around understanding techniques used during breast plastic surgery, as soon as the word plastic is associated with cancer, there is often an unrealistic patient expectation. Reconstructive breast surgery is the term used for reconstruction post-mastectomy, be it immediate, immediate-delayed, or delayed.
The first rules
- Breast reconstruction and oncoplastic surgery should be discussed with all patients prior to surgery
- The vast majority of patients can undergo immediate reconstruction at the time of their cancer surgery (thus avoiding multiple procedures). Many easy techniques that can be learnt and taught to general surgeons
- Understanding the oncology principles and rules in your unit avoids unnecessary complications around reconstruction (such as which patients require radiation)
- Teamwork in the correct surgical environment enables safe enhanced recovery after surgery principles.
- Understand the size of the tumour
- The position of the tumour
- The radiological and tumour information
- The relationship with nipple-areolar complex
- Distance to skin.
- The size of the breast
- The consistency of the breast tissue (fatty breast can be harder to perform oncoplastic techniques on if one does not have experience the tissue pulls apart and areas of fat necrosis result from the inadequate blood supply
- The degree of ptosis
- Previous breast surgery
- Presence of prostheses (type, size, and age).
- Medical illness that may affect surgery
- Habits such as smoking
- Medication that may affect surgery.
BCT techniques are two-fold:
1. Volume displacement
Involves moving the breast tissue around with types of parenchymal flaps
From small rotational flaps to the use of a variety of breast reduction or mastopexy techniques
2. Volume replacement
This involves the use of importing loco-regional tissue in the vicinity of the BCa excision. In our unit, LICAP flaps, thoraco-epigastric flaps and regional local flaps are used commonly (with latissimus dorsi flaps reserved for immediate or immediate-delayed medium breast reconstruction in patients post-primary ChT with inflammatory BCa. Other immediate delay alternatives are also available for inflammatory cancers post-primary ChT.
Most mastectomies in our unit are skin-sparing, with 60% of this being nipple and skin-sparing. This can be either prosthetic or autologous. Prosthetic reconstruction is mainly direct implant reconstruction in our unit without acellular dermal matrixes (ADM). The use of expander or prosthetic with ADM is reserved for a small subset of patients who have skin loss, particularly in the lower poles. Prosthetic reconstruction is done once the need for radiation has been accessed and is used in patients requiring radiation with montelukast with good results.
Latissimus flap reconstruction is reserved in the unit in patients presenting with locally advanced BCa post-primary ChT, including in inflammatory BCas. Currently, a technique called the Goldilocks reconstruction has shown to be as effective.
Most of these patients require immediate, delayed reconstruction involving a nipple-sparing sometimes and (mostly) skin-sparing mastectomy, a 48 hour pathology turn-around on margins (10mm) with margin clearance reconstruction and oncostatin M 48 hours later.
Detailed patient counselling is suggested with a small subset of patients requiring free flaps and strict no time delay to either radiation or ChT being maintained within the unit of a minimum of three weeks and max allowed of six weeks.
The Goldilocks reconstruction
Done with a modification of nipple and skin-sparing through a lateral type 4 approach with the addition of bilateral thoraco-epigastric flaps is offered in some patients with breast ptosis, and over a c cup breast size.
The unit has a high number of locally advanced patients that are managed, including those with stable or responsive metastatic disease that are offered surgery with reconstruction only after a clear assessment of the value add of surgery after a multidisciplinary team discussion.
A ‘less is more’ approach is taken with metastatic patients requesting some form of reconstructive surgery, with the most conventional techniques being BCT with parenchymal flap reconstructions. Pregnant BCa patients requiring surgery also are offered local small parenchymal flap reconstruction. Elderly patients are also offered oncoplastic and breast reconstruction as long as anaesthetic safety has been predetermined.
The use of primary endocrine treatment is offered for frail elderly luminal A BCa patients who wish to undergo surgery. The unit is involved in cryo-surgery for a subset of BCa patients.
Survivorship and navigation
- Does your unit have radiology and oncology navigators helping patients on their cancer journey?
- Do you offer an oncology care physician survivorship programme?
- Are all young BCa patients offered a fertility service and discussion prior to starting treatment?
- What is the unit protocol on which patients are referred for genetic counselling and testing (and when)?
- Which patients are referred for an onco-psychology consult, and when?
- Which patients are referred for lymphoedema physio and when?
- What is the unit policy on complementary oncology care, and how is this managed?
Novel navigation techniques have been adopted at both units. These were conceived at the units involving using trauma coding systems to highlight urgency oncology management needs:
- Colour coded radiology
- Colour coded navigation
- Open access clinic
- Cultural-based navigation.
How has the Covid-19 pandemic affected BCa care?
More robust virtual multidisciplinary meetings with people having the option to attend these and for these sessions to be recorded. In addition, the value of IT specialists ensuring that all can visualise radiology and pathology slides adds to the concept of multidisciplinary review.
The pandemic has also broadened the horizons of oncology treatment options from more neo-adjuvant (primary) oncology care, more minor safer surgeries, lesser radiation options in terms of treatment.
In the private sector, the pandemic has resulted in a more patient-centred approach (with fewer people rushing into surgery (this is a good thing). More women with early-stage hormone-sensitive BCas were treated with endocrine therapy as a holding treatment prior to surgery (this is a good approach in my opinion as it ensures that women have an opportunity to assess where and what treatments they want).
The good so far:
- A more patient-centred approach
- More virtual and telephonic access to doctors (this should not replace a clinical examination
- Virtual multidisciplinary unit meetings resulting in more doctors accessing inter-disciplinary patient decision making
- An international trend to home-based oncology care and safer systems around surgical hospitalisation.
In my unit, due to an inability of visiting loved ones, an immediate post-surgery phone call by myself re surgery was instituted (this will be a continued service post-Covid). We set up family Teams or Zoom chats, and this has helped when family is located around the world.
Significant issues around BCa are always early diagnosis and treatment availability. The pandemic resulted in fewer women going for their screening mammograms (many women did not screen last year).
Whilst I have not been able to crunch the data yet, more women arrived at HJH breast clinic with advanced cancers. Patient fear of hospitals (general fear around Covid) resulted in non-adherence and late access to care.
Unfortunately, oncology and radiation services for government patients resulted in delays in receiving radiation and some oncology services.
Effect on patients
Some people who are anxious have heightened fears around cancer and Covid, whilst others have many other concerns from financial to dealing with the loss of family members that cancer risks are considered less important.
- Access to care and financial concerns: I have enjoyed running two units and ensuring that all women, irrespective of funding, can access care
- Fear: this is now heightened with Covid. The importance of support and this is where navigation has been so critical and time (take time with decisions, don’t rush into emergency surgery – there is no such thing). Family and friends and having someone to hold a hand and give a hug (the power of a good hug, is something sorely missed) However, like a cancer journey can, like the Comrades, be achieved one small shuffle at a time, so will our getting through this pandemic together.
So a shout out to essential workers and patients … Together we can!
This era of BCa management offers surgeons dynamic and different treatment options for patients. Therefore, today’s oncology surgeon needs to be trained in all aspects of BCa care, from radiology to radiation. In addition, he/she needs to have comprehensive training in different plastic and reconstructive techniques to recognise which patients for which procedures and to ensure that they work with a team of competent specialists, including plastic/reconstructive surgeons, so as allow the best patient outcomes for their patients.
The Milpark based breast centre has pioneered immediate breast reconstruction, multidisciplinary meetings, cancer navigation and survivorship care and received awards for personalised oncology care. The centre is also involved in innovations in cancer care from intra-operative radiation to cryo-surgery. The HJH sister unit has allowed us to ‘bring Africa to the world’ with excellence in cancer care.
- NAPBC Standards and Resources December 2018 – https://www.facs.org/quality-programs/napbc/standards- Access January 2021
- Survival is Better After Breast-Conserving Therapy than Mastectomy ….” 6 Mar. 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4595537/. Accessed 4 Dec. 2017.
- Guidelines and Consensus Documents –2020 https://www.astro.org/Patient-Care-and-Research/Clinical-Practice-Statements
- Radiation for Breast Cancer- 2020 https://www.cancer.org/cancer/breast-cancer/treatment/radiation-for-breast-cancer.html
- “Regional nodal management in the light of the AMAROS trial.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430731/. Accessed 4 Dec. 2017.